Journal Article > Study

This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.

Journal Article > Study

This qualitative analysis found that electronic transmission of new prescriptions is a successfully maturing process. Reported challenges that require future attention include e-renewals and mail-order pharmacy connectivity.

Journal Article > Study

The authors applied human error theory to study consultations for over-the-counter medications in community pharmacies. Their findings suggest that pharmacy staff were unaware of professional guidelines for such communications.

Journal Article > Study

The study, which analyzed prescription drug error claims for 78 group practices, found both direct and indirect relationships between culture, practice structure, and medication errors. The authors believe that better care coordination can improve medication safety in the outpatient environment.

Journal Article > Study

The investigators issued questionnaires to parents in seven community pharmacies to prospectively monitor pediatric adverse drug reactions (ADRs). They found that the system was effective for reporting ADRs.

Newspaper/Magazine Article

This article reports on Target pharmacies' redesign of prescription bottles. The new bottles, designed to support safer outpatient medication use, have a flattened label and are color-coded for each family member.

Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.

Web Resource > Multi-use Website

This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.

Journal Article > Commentary

Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the workload and ineffective computer systems. This commentary explores how to enhance the safety of community pharmacy practice and recommends improvements in reimbursement, quality metrics, training, electronic information tools, and staffing to achieve safe medication use at the community level.

The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.

Researchers examined employee perceptions of safety culture before and after implementation of a pharmacy services call center designed to reduce interruptions across nine community pharmacies. They found that pharmacies with the call centers reported a 9.3% overall improvement in patient safety after implementation.

Journal Article > Commentary

Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.

Journal Article > Commentary

This commentary summarizes opportunities for community pharmacists to engage in efforts to monitor opioid prescribing, reduce hospital readmissions due to nonadherence, and provide counseling to enhance medication safety. The author explores how changes in policy and reimbursement can facilitate these patient safety roles for pharmacists in the ambulatory environment.

In this qualitative study, researchers followed the progress of the improvement work taken on by 10 English community pharmacies that participated in improvement workshops over a 1-year period. Using a behavioral change framework, they were able to describe the pharmacies' progress in their activities as well as identify particular organizational factors facilitating improvement work.

Perspectives on Safety > Interview

Dr. Cohen is President of the Institute for Safe Medication Practices, a nonprofit organization that operates the voluntary and confidential ISMP Medication Errors Reporting Program. He is also coeditor of the ISMP consumer website, chairperson of the International Medication Safety Network, and a consultant to the Food and Drug Administration. We spoke with him about patient safety in the community pharmacy, including challenges associated with production pressures and the importance of reporting concerns.

Many ambulatory electronic health records cannot communicate to pharmacies that medications should be discontinued. In a nationally representative sample, nearly 1% of new prescriptions had discontinuation instructions for other prescriptions embedded within them, a workaround that creates inefficiencies and new safety hazards. A recent interview with Michael Cohen, President of the Institute for Safe Medication Practices, discussed this and other safety concerns that community pharmacies face.

Cases & Commentaries

Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.

Journal Article > Study

Community pharmacy dispensing errors are an important cause of ambulatory adverse drug events. In this academic health system, 5% of prescriptions were dispensed inadvertently—the providers had ordered to discontinue them. Most unintentionally dispensed prescriptions were high-risk medications, such as anticoagulants, insulin, and diuretics.

Journal Article > Study

Under the Safety-I framework, procedural violations in the health care setting might be viewed unfavorably. In the Safety-II framework procedural violations may be seen as necessary modifications within a complex work environment. The authors suggest that applying both frameworks provides deeper understanding of procedural violations in community pharmacies and may facilitate the development of targeted interventions for improving safety.